Executive summary
On Friday 15 May 1998, at approximately 2220 hours, Train 411, a southbound express freight, was mistakenly routed on to the wrong main at Ngaruawahia. This operating irregularity was not responded to appropriately and the train was permitted to continue running in the down direction on the up main to Te Rapa, some 12 km south. Safety issues identified were the training and experience of staff used for relief duties in the Te Rapa signal box, the acceptance by locomotive running staff of inappropriate authorisation and the potential hazard to road traffic at level crossings during the wrong line running. A number of safety actions were taken by the operator and two safety recommendations were made to address the safety issues.
Related Recommendations
Introduce formalised crew resource management training for Train Control Operators, Signalmen and LEs based on the training available in the aviation and marine industries. [SR repeated as SR 006/01 in investigation 00-106]
Reassess the Tranz Rail irregularity follow-up policy to ensure that it is positioned sufficiently towards a corrective action culture as distinct from a punishment culture so that prompt reporting of irregularities is encouraged.